Health Information Management

Refresh your knowledge of core concepts for coding accuracy

HIM-HIPAA Insider, November 17, 2009

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Clinical knowledge is an essential element for capturing severity and MS-DRG assignment, according to Gloryanne Bryant, RHIA, CCS, CCDS, regional managing director of HIM at Kaiser Permanente in Oakland, CA. “When we’re talking about DRG changes and coding changes, it’s important to enhance clinical knowledge,” she said.
Additionally, refresh your knowledge of the following core concepts for coding accuracy:
  • Case-mix index. Track this monthly and look for changes. What is your highest-volume DRG, primary diagnosis, and secondary diagnosis?
  • Accurate and complete coding. Know the Uniform Hospital Discharge Data Set definition of principal diagnosis: “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
  • Physician documentation. This is key to accurate code assignment. Have your clinical documentation improvement specialist determine where improvements are needed.
  • Coding audits. Perform audits regularly to evaluate accuracy and potential over- or undercoding.
“These are great actions to take to ensure accuracy in documentation, case-mix index, and certainly your MS-DRGs,” Bryant said.
Editor’s note: This tip is adapted from the November 2009 issue of Briefings on Coding Compliance Strategies.

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